Provider Demographics
NPI:1609882729
Name:LIM, PROSPERO A (MD)
Entity Type:Individual
Prefix:
First Name:PROSPERO
Middle Name:A
Last Name:LIM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:PROSPERO
Other - Middle Name:A
Other - Last Name:LIM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:452 TOMPKINS AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10305-1760
Mailing Address - Country:US
Mailing Address - Phone:718-727-9340
Mailing Address - Fax:718-727-9340
Practice Address - Street 1:452 TOMPKINS AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10305-1760
Practice Address - Country:US
Practice Address - Phone:718-727-9340
Practice Address - Fax:718-727-9340
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-31
Last Update Date:2015-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1534482084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY06D531OtherMEDICARE PTAN
NYD38916Medicare UPIN
NY06D531OtherMEDICARE PTAN